ENS 50414

v t e ENS Event
04:00 Aug 29, 2014
Title	Agreement State Report - Medical Event
Event Description	The following information was received via facsimile: On August 29, 2014, the licensee made a telephone notification of a medical event which occurred during a skin treatment using a Nucletron microSelecton 106.990 HDR. The Radiation Safety Officer indicated that a decay corrected value for the source activity was used during data entry for the treatment plan. The licensee discovered, after the administration of the treatment fraction, that the software also corrected for decay in determining the exposure time for the fraction. The extra decay correction resulted in a dose approximately twice the prescribed fraction dose of 600 cGy. The licensee has informed the referring physician and held a staff meeting to discuss the circumstances. Any future treatment fractions for the patient will be reviewed and the licensee will review its nine previous skin treatment procedures to determine if additional medical events may have occurred. Additional information, including the administered dose, will be provided by the licensee in its written report. Event Report ID No.:VA-2014-005 A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.

ENS 50414 +/-
Where
Inova Fairfax Hospital Falls Church, Virginia (NRC Region 1)
License number:	610-116-1
Organization:	Virginia Rad Materials Program
Reporting

Agreement State
Time - Person (Reporting Time:+10.85 h0.452 days <br />0.0646 weeks <br />0.0149 months <br />)
Opened:	Charles Coleman 14:51 Aug 29, 2014
NRC Officer:	Donald Norwood
Last Updated:	Aug 29, 2014
50414 - NRC Website
v • d • e

v t e Emergency Notification System
Inova Fairfax Hospital with Agreement State
WEEKMONTHYEAR2014-08-29T04:00:00 [Table view]
[ENS list for Inova Fairfax Hospital]

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